Brief Intake/Assessment Process

The Brief Intake/Assessment is the initial meeting with the client during which the case manager gathers information to address the client's immediate needs to encourage his/her engagement and retention in services.

The Brief Intake/Assessment may also be used to screen clients to determine if they need case management services, and if so, to determine the model of case management most appropriate to meet a client's needs, and to assess the client's willingness and readiness to engage in case management services.

In the Supportive Case Management model, the Brief Intake/Assessment is the sole mechanism for assessing client needs. Documentation from this assessment provides the basis for developing the Brief Service Plan and providing case management services. In Supportive Case Management, a Comprehensive Assessment is not required.

In the Comprehensive Case Management model the Brief Intake/Assessment allows initiation of case management activities until a Comprehensive Assessment can be completed.

Case managers must assure the client's privacy and confidentiality in all phases and activities of case management.

Standard Criteria

Key information, concerning the client, family, caregivers and informal supports is collected and documented to determine client enrollment eligibility, need for ongoing case management services, and appropriate level of case management service.

In AIDS Day Health Care Program (ADHCP): Not applicable

Time requirement:Due within 15 days of referral. Where HIV positive persons are entering services for HIV medical care, due by completion of initial comprehensive medical visit(s).

  1. Immediate needs are identified during the Brief Intake/Assessment process.
  2. Immediate needs are addressed promptly.
  3. Brief Intake/Assessment documentation includes, at minimum:
    1. Basic Information
      • presenting problem
      • contact and identifying information (name, address, phone, birth date, etc.)
      • language spoken
      • demographics
      • emergency contact
      • confidentiality concerns
      • household members
      • insurance status
      • proof of HIV status
      • other current health care and social service providers, including other case management providers
    2. Brief overview of status and needs regarding
      • food/clothing
      • finances/benefits
      • housing
      • transportation
      • legal services
      • substance use
      • mental health
      • domestic violence
      • support system
      • HIV disease, other medical concerns, access to and engagement in health care services
      • prevention of HIV/AIDS transmission
      • prevention of HIV disease progression
  4. Documentation includes appropriate releases, including Authorization for the Release of HIV Confidential Information in accordance with Article 27F, and other releases for information as required by applicable law.
  5. Client is assessed for program eligibility and meets eligibility criteria.
  6. Case Management Policies and Procedures contain guidelines for conducting the Brief Intake/Assessment including staff responsible for and supervisory oversight.

Exceptions

Where HIV positive persons are entering services for HIV medical care, a Brief Intake/Assessment is required by the end of the initial comprehensive medical visit to screen for case management needs. In some medical settings this may involve multiple visits.

A client's acute needs and/or crises are paramount. If the presenting problem requires immediate attention, the Brief Intake/Assessment may be postponed or abbreviated, but should be completed as soon as possible.

In the ADHCP the Screening/Intake process serves the purpose of the Brief Intake/Assessment and provides information for determining appropriateness of admission to the program and identification of immediate service needs. A case manager assigned to the client within the first week of admission is responsible for addressing immediate needs.

Best Practices

Staff with good interviewing skills who can put clients at ease, obtain key personal information, and recognize potentially urgent situations should perform the Brief Intake/Assessment process. Placement into the appropriate case management model and provision of initial case management services depend on utilizing capable, empathetic staff.

Information obtained during the Brief Intake/Assessment should be shared, after client consent, with other providers to coordinate services and avoid duplication of efforts. To increase efficiency, information from an agency's program eligibility screening process may also be used in the Brief Intake/Assessment.

Additional Resources

Sample forms including Brief Intake/Assessment and Screening Questions to Determine Need and Level of Case Management Services are available on the New York State Department of Health web site under the category "Clinical Guidelines, Standards, and Quality of Care."